Report A Claim

If you need to report a claim during our normal business hours (8 a.m. - 4:30 p.m., weekdays, Central Time), please call us at 800-652-9515. For claims requiring immediate attention or to report claims after hours, please call the insurer directly at their respective number.

* required fields are in yellow

Northland:	800-328-5972
Carolina Casualty:	800-874-8053 (weekdays) or 800-457-3390
Dakota Truck Underwriters:	877-585-1117
Empire:	800-228-9283
Maxum:	800-598-6324
The Hartford:	800-327-3636

Insurance Company:
Name of Insured:
Address of Insured:
City:
State:		Zipcode:
Policy #:
Policy Type:	-- choose one-- Truck Public Auto Business Auto Workers Compensation Cargo Other
Effective Date:
Expiration Date:
Date of Loss:
Report Date:
Contact Person:
Phone 1:		Type:	-- choose one-- Home Work Cellular
Phone 2:		Type:	-- choose one-- Home Work Cellular
Fax:
E-Mail Address:
Agency Name:
Agency Contact:
Agency Phone:

Driver Information

Driver's Name:		Driver's Age or DOB:
Reported/New:	Reported New

Accident Location

Address:
City:		State:		Zipcode:
Police Department:
Police Report #:

Insured Vehicle Information

Year:		Make:		Serial #:
Description of Vehicle Damage:
Location of Vehicle:
Cargo:
Cargo Location:

Claimant Information

Name:		Address:		Phone:
Injuries:

Claimant Vehicle Information

Year:		Make:		Serial #:
Description of Damage:
Location of Vehicle:

Additional Information

Brief Description of Accident:
Additional Comments:
Other Pertinent Phone #:		Other Pertinent Phone #: